Coping Mechanism among Parents of Children with Autism Spectrum Disorder: A Review

This review presented the current literature on coping mechanisms among parents of children with autism spectrum disorder (ASD), focusing on types of coping mechanisms among parents and different coping mechanisms between mothers and fathers of children with ASD. A search of published literature in English was conducted using Google Scholar, PsycINFO, Medline, Scopus, CINAHL, EBSCO, Springer, Ovid, PubMed, and Cochrane Library up to February 2020. Overall, 18 articles were relevant to the review. The review included thirteen studies for types of coping mechanisms among parents of children with ASD and five studies for different coping mechanisms between mothers and fathers. Coping mechanisms demonstrated by parents when caring for their child include problem-focused and emotion-focused coping. A comparison between fathers and mothers in our review showed that mothers used emotion-focused coping more than fathers, while fathers used problem-focused coping more frequently than mothers. The review provides an exciting opportunity to advance our knowledge on types of coping mechanisms and gender difference in using coping mechanisms among parents of children with ASD. The review also sheds new light on developing supportive interventions by healthcare providers to improve coping mechanisms among parents of children with ASD.


Introduction
Autism spectrum disorder (ASD) is defined as one of the neurological developmental disorders with moderate to severe impairments in social interactions, communication, cognitive development, and repetitive and restricted behaviors (1). Besides, ASD is described as a group of disorders, including autism or autistic disorder, Asperger syndrome, and pervasive developmental disorder. Among these, autism or autistic disorder is the most common type of ASD (1).
The incidence of ASD varies markedly between countries. The Centers for Disease Control and Prevention estimates that one in 68 children under eight years old is affected by autism. This new estimate is approximately 30% higher than the previous estimate in 2012, with approximately one in 88 children. The incidence rate of ASD in males was five times higher than in females, which was one in 42 boys versus one in 189 girls (2). There is no doubt that the core characteristics of ASD are behavioral problems and socio-communication skill deficits, which lead to significant stress in families with these children (3-5).
To date, numerous studies have revealed that parents of children with ASD experience a higher level of stress than parents of children with other developmental disabilities (6-9). These extensive studies examined factors associated with the high-stress level among parents of children with ASD. Some have found that the parent's gender is strongly associated with the high-stress level (10- 14). Further studies have suggested that parenting stress is associated with younger parents and younger male children (15)(16)(17)(18). Also, studies have reported that parents experience a higher level of stress in the period right after the diagnostic given (15,(19)(20). Studies also reported that parents with lower education levels and monthly income experienced a higher stress level (12,15,(21)(22). Furthermore, previous studies reported that a high parenting stress level was associated with other factors such as child behavioral problems (23-24) and lack of professional and social support (25-27).
Coping with a stressful situation is challenging (28). According to Lazaras and Folkman (29), coping refers to the behavioral and cognitive abilities to manage and deal with one's internal and external demands in any stressful situation. With this regard, Lazarus and Folkman (29) suggested that a coping mechanism could be either problemfocused or emotion-focused. Problem-focused coping involves identifying the source of the stress and implementing strategies to eliminate or change the stressor. Emotion-focused coping deals more with changing the emotions associated with the stressors. There is evidence that coping plays a crucial role in mastering, reducing, or tolerating stress and determining whether a stressful event is an adaptive or maladaptive process (30-31).
Coping mechanisms that are often demonstrated by parents when caring for their child with ASD include support from family, friends, social support groups, other parents of children with ASD, service providers, advocacy, and religion (32-33). Furthermore, a parent's ability to deal with a high-stress level depends on the effectiveness and Iran J Child Neurol. Winter 2022 Vol. 16 No. 1 quantity of the coping mechanism they employ in managing the demands of stressors associated with a child with ASD (34). This review provided an overview of the evidence for coping mechanisms used by parents of children with ASD. This literature review included studies published from 1980 to February 2020. Also, the search was limited to articles presented in the English language. The following keyword search terms were used "Autism spectrum disorder," " Autism," " autistic disorder," "parent mental health," " parenting stress," " coping," " coping mechanism," " coping mechanism," " coping skills," " parents coping style." The advanced search terms were a combination of "Autism spectrum disorder," OR "Autism," OR "autistic disorder," "parent mental health," OR "parenting stress," "coping mechanism," OR "coping strategies," OR "coping skills," OR "parents coping mechanism."

Inclusion and exclusion criteria
All the selected articles met the following inclusion criteria: (1) they were published in English; (2) they examined coping mechanisms, coping strategies, or coping skills as their main objectives; (3) they involved quantitative and qualitative approaches.
Letters and case reports were excluded.

Included and excluded studies
As of February 2020, the search strategy yielded 1041 articles. All the articles were written in the English language with a full text/methodology section following the inclusion and exclusion criteria. However, 55 articles were found to be duplicates. Finally, 18 articles were included in the review. Figure 1 illustrates a flowchart of the process of selecting relevant articles.

Results
All the identified relevant articles were extensively reviewed to identify themes related to coping mechanisms among parents of children with ASD.
Two themes were identified: types of coping mechanisms among the parent of children with ASD and different coping mechanisms between mothers and fathers of children with ASD.

Types of coping mechanisms among parents of children with ASD
Research has been conducted on coping mechanisms since the 1980s. Several researchers have attempted to identify types of coping mechanisms among parents of children with ASD.
Zablotsky and colleagues (34) reported a strong relationship between emotion-focused coping, such as social support, and parents' psychological Lin and colleagues (42) conducted a qualitative case study to investigate the coping mechanism among 17 parents of children with ASD. In contrast, the authors found that seeking support, adjusting to self-change, and developing treatments for their children were problem-focused and emotionfocused coping strategies used by the parents. Furthermore, a qualitative study by Luong et al. (43) reported that parents used nine coping mechanisms, A total of 136 parents were assigned to one of the two groups: Group 1 (ASD, n = 73) and Group 2 (typical development, n = 63). In their study, the coping mechanism was assessed using the Brief COPE questionnaire, a self-report questionnaire containing 28 items on a four-point Likert scale.
The study results indicated that active avoidance that parents of children with ASD used problemfocused coping mechanisms frequently, which is congruent with the report by Kiami and Goodgold (39). Regarding qualitative findings, Gona et al. (44) found that both problem-focused and emotionfocused coping mechanisms were used by parents of children with ASD, which is supported by Lin et al. (42) and Luong et al. (43). In contrast, Gray (41) found that parents used only emotion-focused coping.

In Conclusion
This review focused on identifying types of coping mechanisms and different coping mechanisms between mothers and fathers of children with ASD. Previous literature studies provided a consistent picture to agree that parents use two main coping mechanisms when caring for their child with ASD, namely, problem-focused coping and emotion-focused coping. In addition, previous studies showed that emotion-focused coping was widely demonstrated by mothers, whereas fathers used problem-focused as a coping mechanism. As a result, this review offers essential insights into research as a key to developing an intervention support program that mainly focuses on coping mechanisms among fathers and mothers of children with ASD and improving the adaptation to stressful events.